Counterpoint Insurance, Inc. Home, Business, Auto, Personal Umbrellas, Insurance in NH

Home Owners Insurance Application
To get us all the information we need to provide you with a comprehensive, competitive price for your insurance coverage, please complete and submit this secure, online application, and we'll get your price quote to you pronto!

Personal Information

Named Insured	Date of Birth (format mm/dd/yyyy)
Marital Status Single Married	Social Security # (format xxx-xx-xxxx)
Second Named Insured	Date of Birth (format mm/dd/yyyy)
Marital Status Single Married	Social Security # (format xxx-xx-xxxx)
Address	Previous Address (if less than 2 years)
Home Phone (format xxx-xxx-xxxx)	Cell Phone (format xxx-xxx-xxxx)
Work Phone (format xxx-xxx-xxxx)	Fax (format xxx-xxx-xxxx)
Email Address	Business Owner Yes No
Vehicle Insurance Carrier	Vehicle Insurance Expires (format mm/dd/yyyy)
Life Insurance Yes No Interested

Current Coverage Information


Dwelling $	Personal Property $
Liability $	Medical $
Deductible $

Dwelling Information

Year Built

(format yyyy)

Style

Square Footage

Trampoline
Yes
No

Pool
Yes
No

Type

Pets
Yes
No

Type

Roof Type

Age

Heat Type

Age

Oil Tank Location

Electrical Type

Age

Pl umbing Type

Age

# Bedrooms

# Bathrooms

Living Room
Kitchen
Laundry Room
Dining Room
Family Room
Den/Study

Walk-in Closet
Enclosed Porch
Half Bathroom
Central Air
Foyer/Entrance Hall
Fireplace/Woodstov

Deck Size

Breezeway Sq Ft

Open Porch Sq Ft

Screened Porch Sq Ft

Basement
Finished
Unfinished

% Finished

# Garages

Garage Type
Attached
Detached

Exterior Walls
Wood
Brick
Siding

Interior Walls		%
Paint
Paper
Paneling
Ceramic
Tongue & Groove

Flooring		%
Wall to Wall
Hardwood
Cramic
Linoleum

Miles to Fire Department

Distance from Fire Hydrant

Scheduled Items (i.e., jewelry, furs, antiques, guns)

Current Carrier Information

Insurance Carrier	Premium $
	Expiration Date
Losses/ Claims/Comments